Quantification of gaze reaction time in infants with Pediatric Perimeter.

PURPOSE: We quantified the eye/head (gaze) reaction time in infants to establish a normative database for the Pediatric Perimeter device. Additionally, we tested the hypothesis that gaze reaction time will reduce with age. METHODS: A cross-sectional study was conducted. Healthy infants between 3 to 10 months of age were recruited. Peripheral visual field stimuli (hemifield and quadrant stimuli) were presented in the Pediatric Perimeter device. Infant's gaze to these stimuli was observed, documented in real time, and video recorded for offline analysis. RESULTS: A total of 121 infants were tested in three age group bins [3-5 months, n = 44; >5-7 months, n = 30 and >7-10 months, n = 47]. Overall, 3-5 months old had longer reaction time when compared to the older infants particularly for stimuli presented in the quadrants (Kruskal-Wallis, p<0.038). A significantly asymmetric difference (p = 0.025) in reaction time was observed between the upper (median = 820ms, IQR = 659-1093ms) and lower quadrants (median = 601ms, IQR = 540-1052ms) only for the 3-5 months old infants. CONCLUSION: This study provides the normative gaze reaction time of healthy infants. With increase in age, there is reduction in reaction time and disappearance of reaction time asymmetry in quadrant stimuli. The longer reaction time for upward gaze could be due to delayed maturation of neural mechanisms and/or decreased visual attention.

Predictors of CPAP Failure - 10 years' Data of Multiple Trials from a Single Center: A Retrospective Observational Study.

OBJECTIVES: To identify risk factors and outcomes associated with early failure of nasal continuous positive airway pressure (CPAP) in premature infants with respiratory distress (RD). METHODS: This is a retrospective observational study of all the preterm infants with RD primarily supported on nasal CPAP and included in CPAP trials conducted at the study site. Data was collected from the raw excel sheets of the previous trials but limited to eligible patients from study site. Early CPAP failure was defined as the need for mechanical ventilation in the first 72 h after birth. Predictor variables for CPAP failure included baseline maternal and infant characteristics, CPAP care practices, morbidities and adjuvant therapies. The morbidities and outcomes were compared among infants with CPAP failure and CPAP success. RESULTS: Six hundred and fifty-two infants were enrolled in the study. Early CPAP failure was seen in 96 infants (14.7%, 95% CI: 12%-17.5%). On logistic regression, adjusting for gestation and year of study, time of starting CPAP in hours (OR 1.01, 95% CI: 1.003-1.013), time of surfactant administration in hours (OR 1.12, 95% CI: 1.05-1.19), InSurE (Intubate Surfactant Extubate) (OR 2.7, 95% CI: 1.43-5.06) and higher starting FiO2 (OR 1.03, 95% CI: 1.01-1.05) predicted early CPAP failure. Neonatal morbidities and hospital duration were significantly higher in infants who failed CPAP. CONCLUSIONS: Early starting of CPAP, InSurE, early surfactant administration, lower CPAP pressures and lower FiO2 at starting of CPAP were the important determinants of success.

Mutation spectrum of the Norrie disease pseudoglioma (NDP) gene in Indian patients with FEVR.

PURPOSE: Mutations in the Norrie disease pseudoglioma (NDP; Xp11.3) gene have been involved in retinal blood vessel formation and neural differentiation and are implicated in familial exudative vitreoretinopathy (FEVR) cases. However, the role of the gene has not been explored in the Indian context. Thus, this study was designed to understand the involvement of NDP among Indian patients with FEVR. METHODS: The study cohort comprised 225 subjects, including unrelated patients with FEVR (n = 110) and ethnically matched healthy subjects (n = 115) recruited from a tertiary eye care center in India. The entire coding regions, intron-exon boundaries, along with the 5' and 3' untranslated regions of NDP were screened with resequencing following standard protocols. The spectrum of the observed variants was analyzed in conjunction with data available from other populations. RESULTS: Eight potentially pathogenic mutations (p.His4ArgfsX21, p.Asp23GlufsX9, p.Ile48ValfsX55, p.His50Asp, p.Ser57*, p.Gly113Asp, p.Arg121Gln, and p.Cys126Arg, including five novel ones), were observed in the coding region of the NDP gene in ten unrelated FEVR probands (9%). The novel changes were not observed in the control subjects and were unavailable in the dbSNP, ESP5400, NIEHS95, and ExAC databases. All probands with NDP mutations exhibited classical features of the disease as observed among patients with FEVR worldwide. CONCLUSIONS: This is perhaps the first study to demonstrate the involvement of NDP among patients with Indian FEVR that further expands its mutation spectrum. The data generated could have broad implications in genetic counseling, disease management, and early intervention for a better prognosis in FEVR.

Acute and subchronic toxicity analysis of surface modified paclitaxel attached hydroxyapatite and titanium dioxide nanoparticles.

Nanoparticles are widely used for targeted drug delivery applications. Surface modification with appropriate polymer and ligands is carried out to target the drug to the affected area. Toxicity analysis is carried out to evaluate the safety of the surface modified nanoparticles. In this study, paclitaxel attached, folic acid functionalized, polyethylene glycol modified hydroxyapatite and titanium dioxide nanoparticles were used for targeted drug delivery system. The toxicological behavior of the system was studied in vivo in rats and mice. Acute and subchronic studies were carried out. Biochemical, hematological, and histopathological analysis was also done. There were no significant alterations in the biochemical parameters at a low dosage. There was a small change in alkaline phosphatase (ALP) level at a high dosage. The results indicate a safe toxicological profile.

Early routine versus late selective surfactant in preterm neonates with respiratory distress syndrome on nasal continuous positive airway pressure: a randomized controlled trial.

BACKGROUND: Preterm neonates with respiratory distress syndrome (RDS) benefit from early application of nasal continuous positive airway pressure (nCPAP). However, it is not clear whether surfactant should be administered early as a routine to all such infants or later in a selective manner. OBJECTIVE: It was the aim of this study to compare the efficacy of early routine versus late selective surfactant treatment in reducing the need for mechanical ventilation (MV) during the first week of life among moderate-sized preterm infants with RDS being supported by nCPAP. METHODS: Infants born at 28(0/7) to 33(6/7) weeks of gestation with RDS and on nCPAP were randomly assigned within the first 2 h of life to early routine surfactant administration by the InSurE technique (early surfactant group) or to late selective administration of surfactant (late surfactant group). The primary outcome was need for MV in the first 7 days of life. RESULTS: Among 153 infants randomized to early (n = 74) or late surfactant (n = 79) groups, the need for MV was significantly lower in the early surfactant group (16.2 vs. 31.6%; relative risk 0.41, 95% confidence interval 0.19-0.91). The incidence of pneumothorax (1.9 vs. 2.3%) and the need for supplemental O2 at 28 days (2.7 vs. 8.9%) were similar in the two groups. CONCLUSION: Early routine surfactant administration within 2 h of life as compared to late selective administration significantly reduced the need for MV in the first week of life among preterm infants with RDS on nCPAP.

Kangaroo Mother Care in Kangaroo ward for improving the growth and breastfeeding outcomes when reaching term gestational age in very low birth weight infants.

AIM: To study the effect of Kangaroo mother care in the Kangaroo ward in comparison with conventional care at neonatal unit on growth and breastfeeding in very low birth weight infants at 40 weeks' corrected gestational age. METHODS: One hundred and forty neonates with birth weight <1500 g were randomized. The primary outcome was the average weight gain (g/kg/day) from the time of randomization to term gestational age. RESULTS: Mean birth weight, age in days and weight at randomization were similar in both the groups. At term gestational age, average weight gain (g/kg/day) post randomization (23.3 ± 8.7 g vs. 22.64 ± 9.1 g, p = 0.67) and breastfeeding rate (85.9% vs. 87.0%) were comparable. There was no difference in weight gain (g/kg/day) from randomization to hospital discharge between the Kangaroo care group and conventional care group (18.01 g vs. 15.64 g, p = 0.12). Mortality, morbidities like sepsis, hypothermia, apnoea, hypoglycaemia and duration of hospitalization were equally distributed. On average, 11.5 days of intermediate care were saved in the kangaroo group. CONCLUSION: Kangaroo mother care in the Kangaroo ward is as effective as conventional care in the neonatal unit without any increase in morbidity or mortality in stable VLBW infants.

Growth and nutritional status at corrected term gestational age in very low birth weight infants.

OBJECTIVE: To evaluate the growth and nutritional status at term (39-41 weeks) corrected gestational age in VLBW infants and to study the predictors of malnutrition. METHODS: This Cross-sectional study was conducted in a tertiary care perinatal centre with level III NICU. All Inborn VLBW infants who were discharged alive from the hospital during the study period from January 2008 through June 2009 were included in this study. Relevant perinatal, clinical and anthropometry data were collected at birth, at hospital discharge and at term gestation. Primary outcome was considered as Z scores of weight, occipitofrontal circumference, length and predictors of postnatal malnutrition (z-score for weight ≤2SD) at term gestation. RESULTS: The mean gestational age and the mean birth weight of study subjects were 31.03 ± 2.18 weeks and 1195.28 ± 191.25 g respectively. Twenty-six (15%) infants had birth weight less than 1,000 g and 65 (37.4%) infants were of gestation less than 31 weeks. The mean weight, the mean length and mean occipitofrontal circumference (OFC) at term gestation were 2367.32 ± 521 g, 43.72 ± 3.3 cm and 32.65 ± 1.6 cm respectively. The mean z scores for weight, length and OFC at term gestation was -1.66 ± 1.2, -1.98 ± 1.3 and -0.48 ± 0.7 respectively. Forty three percent (n = 75) infants were malnourished. Birth weight (p = 0.005), gestational age (p = 0.001), z-score at birth (p = 0.001), female sex (p = 0.004), duration of oxygen (p = 0.008), duration of hospitalization (p = 0.005) and average post discharge weight gain per day (p < 0.001) predicted malnutrition. CONCLUSIONS: There is a high prevalence of postnatal malnutrition in VLBW infants. Poor intrauterine growth, female sex, lower birth weight, lower gestation, infant sickness and poor post-discharge weight gain contribute significantly to postnatal malnutrition.

Early neonatal morbidities in late preterm infants.

OBJECTIVES: To compare early neonatal morbidity (within first 7 days of life) in late preterm infants with term infants. STUDY DESIGN: Prospective cohort study. SUBJECTS: All live inborn late preterm infants (34 0/7 to 36 6/7 weeks) and term infants (37 0/7 to 41 6/7 weeks). OUTCOME: Any of the predefined medical conditions listed in the study, resulting in post- delivery inpatient hospital observation, admission, or readmission in first 7 days of life. RESULTS: 363 late preterm infants and 2707 term infants were included in study. Two hundred fifty seven (70.8 %) of late preterm and 788 (29.1%) of term infants had at least one of the predefined neonatal conditions. Late preterm infants were at significantly higher risk for overall morbidity due to any cause (P<0.001; adjusted Odds Ratio (OR): 5.5; 95% CI: 4.2-7.1), respiratory morbidity (P<0.001; adjusted OR: 7.5; 95% CI: 4.2-12.3), any ventilation (non invasive or invasive) (P=0.001; adjusted OR: 4.2; 95% CI: 2-8.9), jaundice (P<0.001; adjusted OR: 3.4; 95% CI: 2.7-4.4), hypoglycemia (P<0.001; adjusted OR: 4.5; 95% CI: 2.6-7.7), and probable sepsis (P<0.001; adjusted OR: 3.2; 95% CI: 1.6-6.5). The incidence of morbidities increased from 23% at 40 weeks to 30%, 39.7%, 67.5%, 89% and 87.9% at 38, 37, 36, 35 and 34 weeks, respectively (P<0.001). CONCLUSION: Compared with term infants, late preterm infants are at high risk for respiratory morbidity, need of ventilation (non invasive or invasive), jaundice, hypoglycemia, sepsis, and probable sepsis. All gestations except 39 weeks were at significantly higher risk for morbidity with 40 weeks as reference term.

Congenital chylothorax--successful management with chemical pleurodesis.

Congenital chylothorax is a rare entity which is characterized by abnormal accumulation of chyle in pleural cavity. Chylothorax presenting as non-immune hydrops is even rarer. We report a case of congenital bilateral chylothorax presenting as non immune hydrops and managed successfully with chemical pleurodesis. A term male baby presented at birth with bilateral pleural effusions and subcutaneous edema. It was initially managed with ventilation and intercostals drainage (ICD). After the initiation of feeds, re-accumulation of pleural fluid led to the diagnosis of congenital chylothorax. Management with ICD and octreotide was unsuccessful but responded to chemical pleurodesis with 4% povidine iodine done on 3 separate occasions.

Bubble CPAP for respiratory distress syndrome in preterm infants.

OBJECTIVES: To ascertain the immediate outcome of preterm infants with respiratory distress syndrome (RDS) on Bubble CPAP and identify risk factors associated with its failure. STUDY DESIGN: Prospective analytical study. SUBJECTS: Inborn preterm infants (gestation 28 to 34 weeks) admitted to the NICU with respiratory distress and chest X ray suggestive of RDS. INTERVENTION: Bubble CPAP with bi-nasal prongs. PRIMARY OUTCOME: CPAP failures infants requiring ventilation in the first one week. RESULTS: 56 neonates were enrolled in the study. 14 (25%) babies failed CPAP. The predictors of failure were; no or only partial exposure to antenatal steroids, white-out on the chest X-ray, patent ductus arteriosus, sepsis/pneumonia and Downes score > 7 or FiO2 > or = 50% after 15-20 minutes of CPAP. Other maternal and neonatal variables did not influence the need for ventilation. Rates of mortality and duration of oxygen requirement was significantly higher in babies who failed CPAP. Only two infants developed pneumothorax. No baby had chronic lung disease. CONCLUSION: Infants with no or partial exposure to antenatal steroids, white-out chest X-ray, patent ductus arteriosus, sepsis/pneumonia and those with higher FiO2 requirement after initial stabilization on CPAP are at high risk of CPAP failure (needing mechanical ventilation). Bubble CPAP is safe for preterm infants with RDS.

Light emitting diodes versus compact fluorescent tubes for phototherapy in neonatal jaundice: a multi center randomized controlled trial.

OBJECTIVE: To evaluate whether light-emitting diode (LED) phototherapy is as efficacious as compact fluorescent tube (CFT) phototherapy for the treatment of non-hemolytic jaundice in healthy term and late preterm neonates. STUDY DESIGN: Multi centre open label randomized controlled trial. SETTING: Four tertiary care neonatal units. SUBJECTS: Healthy term and late preterm neonates with non-hemolytic jaundice. INTERVENTION: Single-surface LED or CFT phototherapy. PRIMARY OUTCOME VARIABLE: Duration of phototherapy. RESULTS: A total of 272 neonates were randomized to receive LED (n=142) or CFT (n=130) phototherapy. The baseline demographic and biochemical variables were similar in the two groups. The median duration of phototherapy (IQR) in the two groups was comparable (26 (22-36) h vs. 25(22-36) h; P=0.44). At any time point, a similar proportion of neonates were under phototherapy in the two groups (log-rank test, P=0.38). The rate of fall of serum total bilirubin (STB) during phototherapy and the incidence of failure of phototherapy were also not different. An equal proportion of neonates had a rebound increase in STB needing restarting of phototherapy. Side effects were rare, comparable in the two groups and included hypothermia, hyperthermia, rash, skin darkening and dehydration. CONCLUSIONS: LED and CFT phototherapy units were equally efficacious in the management of non-hemolytic hyperbilirubinemia in healthy term and late preterm neonates.

Pilot study on in vivo evaluation of retinal vascular maturity in newborn infants in the context of retinopathy of prematurity.

PURPOSE: To study the extent of retinal vascularization at birth. DESIGN: Prospective masked observational case series. METHODS: One hundred ten neonates, at different weeks of gestation and birth weights (BWs), had dilated fundus evaluation for zone of retinal vascularization by a masked observer. Maternal and neonatal factors were ascertained by a masked pediatrician. RESULTS: Irrespective of risk factors, eight of nine babies who were born at <30 weeks of gestation and at <1500 g BW had immature retina. Those babies who were born at >34 weeks of gestational age and at >1700 g BW had mature retina. Babies who were born between 31 to 34 weeks of gestation and at 1501 to 1700 g BW had variable extent of retinal vascularization at birth. Vascularization was affected by maternal anemia and the need for oxygen for >48 hours. CONCLUSION: There exists considerable variability in the extent of retinal vascularization in infants who are born between 31 to 34 weeks of gestation. Modifiable maternal and fetal factors could influence extent of this vascularization birth.